Excerpt # 24: A Near Tragedy

Excerpt # 24: A Near Tragedy

M. Bakri Musa (ww.bakrimusa.com)

Back to the clinical side, there was one memorable but very embarrassing and potentially tragic episode at GHKL during my brief association with UKM. The son of a “very, very important person” (VVIP) was having minor surgery. Circumcision is normally done as an outpatient and under local anesthesia, except in rare circumstances and with specific medical indications. The surgeon for this patient was my colleague Mahmud.

            A few days before the surgery, Mahmud confided in me his anxiety about the anesthesiologist who would be doing the case as it would be done under general anesthesia. That was unusual in itself. UKM had two academic anesthesiologists, one young and very competent whom I called with great fondness as Little Ahmad. He was not to be confused with another anesthesiologist, Dr. “Big” Ahmad, who was in the government service. The other UKM anesthesiologist was much older and by now consumed with his administrative chores at the dean’s office. He had been away from clinical medicine for some years. This senior academic anesthesiologist decided that he would do this case.

            Both Mahmud and I were aware of the ultra-sensitive nature of the dilemma. To be prepared, I arranged for young Ahmad to be on standby outside the operating room for that morning, ready to take over regardless of what feathers we would ruffle. Patient safety was our top and only priority.

            On that fateful morning, the young patient was wheeled in and the academic anesthesiologist took over with his usual elaborate ritual, making a big show of it. Mahmud was there and I entered the room on the pretext of making small talk with him on how to do the procedure the “right” or Muslim way.

            Then with the patient induced, sure enough, something happened. The anesthesiologist had difficulty intubating, and he started yelling at the nurses to get an endotracheal tube of a different size. Anytime someone yells, especially your superior and in a tense situation, everyone gets flustered. The nurses could not find the right-sized tube fast enough.

            Within seconds the orderliness and discipline of the operating suite degenerated into a scene resembling an oriental bazaar – chaotic. Except that at the bazaar, the activities were purposeful and productive. In our suite by contrast, the nurses were scurrying here and there, drawers drawn open and then slammed shut, likewise cupboard doors. The academic anesthesiologist’s eyes were darting in all directions, his voice rising with increasing desperation. He was doing everything except keeping his eye on the patient who was now motionless and not breathing.

            As per my earlier arrangement, I signaled behind my back to young Ahmad who was standing outside. He stepped in, bagged the patient, and with no difficulty slipped in a smaller tube that he had in the back pocket of his scrubs (together with a few other sizes anticipating this problem). By the time the attending anesthesiologist turned to his patient, everything was already settled and I continued with my casual conversation with Mahmud as if nothing had happened. Another day at the office! With everything now under control, young Ahmad slipped out and Mahmud started his surgery. The procedure ended with no further incident.

            The beginning and end are the two critical times during surgery. When I operate on children, I make it a practice to hold my breath once my patient is induced, and hold it until he is successfully intubated and ventilated. When I ran of breath, I know then that my patient has too. I would then tell the anesthesiologist to bag the patient (that is, breathe for him). Even today with special oxygen monitors I still hold on to that old practice, especially with my pediatric patients.

            Today’s operating rooms have a mandatory preoperative check-list adapted from long-established airline cockpit pre-flight routines. We call it “surgical pause” where we re-check the patient’s identity, procedure to be performed, laterality with respect to either left or right side, all to ensure that the wrong limb is not being operated on, or God forbid, the wrong patient. Prudent anesthesiologists carry endotracheal tubes one size smaller and one bigger than what they would anticipate using, like young Ahmad did forty years ago.

            The hazards of today’s modern operating rooms are of a different nature, of false signals, what with so many sensitive electronic monitors on the patient, each with its own warning peeps such that the beginning of an operation sometimes simulate the jungle at dusk with its cacophony of warning sounds from faulty connections. Those breed a new risk – the tendency to ignore them, “alarm fatigue.” I am reminded of an old morbid joke about a pilot’s last transmission from his doomed aircraft just before it crashed, “That damn alarm is acting up again!”

            I had another incident of a different and non-clinical nature, this time involving only a VIP. One day my secretary frantically gestured to me to answer the phone while I was busy in the out-patient clinic. I ignored her. She rushed to interrupt me with a note, “Tan Sri Hamzah on the line!”

            I had no idea who he was so I asked her to take the number so I could call him back. Later in the calm of my private office about to return the call, she stepped in and gingerly closed the door behind her. “Did you know who was that Tan Sri?” she whispered, not hiding her anxiety. She went on to illuminate me on this illustrious son of Malaysia. He was the brother-in-law of Tun Razak and a minister in his own right.

            I paused, to compose my profuse heartfelt apology before dialing. With her girlish grin, she then said how glad she was that I didn’t take the call. Otherwise I would have been inundated with all the big shots wanting their sons to be circumcised by me. When she left, I made my call. It was my luck that he was out. My unintended snub that morning was my savior.

Next:  Excerpt # 25: Unexpected Reminders of Canada

Excerpted from the author’s second memoir: The Son has Not Returned. A Surgeon In His Native Malaysia, 2018